BARTON HOUSE GROUP PRACTICE PATIENT REGISTRATION FORM Name Address

Email Address:Daytime telephone No

Date of BirthIf you are over 75,You will be given a named GP

Place of Birth

Are you applying for Asylum? Yes N/A

Height: Weight: BP: Please ask reception to show you to the Blood Pressure/Weight Height Machine

Date of last tetanus if known Are you allergic to any medication? If so, what type?

Are you a carer or cared for by a carer?

Carer Cared for by a carer

Do you smoke? Yes No If you smoke, how many per day?

Do you roll your own cigarettes?Yes No

If you do not smoke now, have you ever smoked? Yes No

How many units of alcohol do you drink in one week? 1 unit=½ pint/1 short/1 glass of wine

Has any member of your family (blood relation only and not including yourself) ever suffered from the following:

Heart Disease Yes No If yes, who and at what age?

Diabetes Yes No If yes, who?

Stroke Yes No If yes, who?

High Blood Pressure Yes No If yes, who?

Have you ever been in contact with anyone who suffers from TB?If so, who:When were you in contact?(Receptionist please make appointment for New Patient H/C)

Is any member of your family registered with this practice? If yes Please provide full names and date of birth.

Are you allergic to any medications?

Are you allergic to anything else?

[Type text]For Office Use only. Date entered on EMIS:

Initials:Is the patient over 75?

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Patient Profiling Form

Name DoBPlease answer these questions. The information will help us plan services for our patients. Giving us this information is voluntary.

What do you consider to be your ethnic origin?White British ArabWhite Irish KosovoTraveller AlbanianGreek BosnianTurkish CroatianKurdish SerbianEstonian/Latvian/Lithuanian Other YugoslavOther White Jewish

British Asian Mixed AsianBengali/British Bengali Pakistani/British PakistaniIndian British Indian Sri LankanTamil SinhaleseChinese VietnameseJapanese FilipinoOther Asian

Black African Mixed BlackBlack Caribbean Mixed White/Black CaribbeanSomali Mixed White/Black AfricanBlack British Mixed White AsianEast African Asian Middle EasternCaribbean Asian Other BlackAny other mixed Other non mixed

I Do not wish to state my ethnicity

In which language would you most prefer us to provide a service to you?English AmharicBengali Sylheti CzechBengali Standard FarsiHindi FrenchUrdu PolishGuajarati PortugueseCantonese RussianVietnamese SpanishSomali British Sign LanguagePunjabi Spoken WordTurkish ArabicAlbanian Other: please specify

If the service is provided in English, do you need an interpreter/advocate?Yes I do No I do not

[Type text]For Office Use only. Date entered on EMIS:

Initials:Is the patient over 75?

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Past and Present Health conditions: Do you currently from any of the following? Please tick where appropriate

Yes NoAsthma/COPDCancerDiabetesHeart DiseaseHigh Blood PressureHigh CholesterolStroke/TIAAny other illnesses

If yes to any of the above please make an appointment with a nurse/hca for new Patient Health Check

Female Only

Have you ever had a PAP/Smear test: Please tickYes No

If yes date of last test:Result of last test:

Have you ever had an abnormal smear (please give details):

Have you ever had a colposcopy (please give details):

Immunisations - Children Under 16 only – Please give reception the red book and they will photocopy the immunisation page. If you do not have a red book the nurse will ask you for your immunisation information on your first visit.

[Type text]For Office Use only. Date entered on EMIS:

Initials:Is the patient over 75?

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Name: Date of Birth: Male /Female

Alcohol Consumption Questions

Scoring System Your Score0 1 2 3 4

How often do you have a drink thatcontains alcohol? Never Monthly or

less

2 - 4 times per

month

2 – 3 times per

week

4+ times per week

How many standard alcoholic drinksdo you have on a typical day whenyou are drinking? 1 - 2 3 - 4 5 - 6 7 - 8 10+

How often do you have 6 or morestandard drinks on one occasion? Never Less than

monthly Monthly Weekly Daily or almost daily

How often in the last year have youfound you were not able to stopdrinking once you had started?

Never Less than monthly Monthly Weekly Daily or

almost daily

How often in the last year have youfailed to do what was expected ofyou because of drinking?

Never Less than monthly Monthly Weekly Daily or

almost daily

How often in the last year have youneeded an alcoholic drink in themorning to get you going?

Never Less than monthly Monthly Weekly Daily or

almost daily

How often in the last year have youhad a feeling of guilt or regret afterdrinking?

Never Less than monthly Monthly Weekly Daily or

almost daily

How often in the last year have you notbeen able to remember what happenedwhen drinking the night before?

Never Less than monthly Monthly Weekly Daily or

almost daily

Have you or someone else beeninjured as a result of your drinking? No

Yes, but not in the last year

Yes, during the last year

Has a relative/friend/doctor/healthworker been concerned about yourdrinking or advised you to cut down?

NoYes, but not in the last year

Yes, during the last year

Scoring: 0 - 7 = sensible drinking, 8 - 15 = hazardous drinking,

16 - 19 = harmful drinking, 20+ = possible dependence

[Type text]For Office Use only. Date entered on EMIS:

Initials:Is the patient over 75?

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SCORE

[Type text]For Office Use only. Date entered on EMIS:

Initials:Is the patient over 75?

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NameDoB

Accessible Information Standard

The Accessible Information Standard aims to ensure that patients (or their carers) who have a disability or sensory loss receive information they can access and understand. For example in large print, braille or via email

Please fill in the questionnaire below, your responses will be added to your medical record for information.

Do you have any communication needs? Yes I do No I do not

If yes please give details …………………………………………...

Do you have any special communication requirements?Yes I do No I do not

If Yes please give details …………………………………………

Do you need a format other than standard print?Yes I do No I do not

If you have a visual impairment do you require:Brail: Yes No Large Print: Yes No

How do you prefer to be contacted? ………………………………

How would you like us to communicate with you? ………………..………………………………………………………………………

Can you explain what support would be helpful when accessing the surgery? …………………………………………………………….………………………………………………………………………

What is the best way to send you information? ………………………….…………………………………………………………………

YOUR DATA MATTERS TO THE NHS - National Data Opt-out[Type text]For Office Use only. Date entered on EMIS:

Initials:Is the patient over 75?

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The NHS wants to make sure you and your family have the best care now and in the future. Your health and adult social care information supports your individual care. It also helps us to research, plan and improve health and care services in England.Unless you have chosen to opt out, your confidential patient information can be used for research and planning. This online service allows you to make or change your decision at any time. You can also download a form to manage a choice on behalf of another individual by proxy.

You may contact the NHS Digital Contact Centre to verify your identity and discuss your data sharing choices. We may be able to guide you through the online service or set a choice on your behalf.

https://www.nhs.uk/your-nhs-data-matters/

Call: 0300 303 5678

Didn’t know you had opted out of NHS Digital sharing your information? Some GP surgeries automatically registered the original opt-out on behalf of their patients.

It is likely that your GP surgery would have told you that they were doing this, but it may have been several years ago. Also, if you have changed GP surgery, it is possible that the original opt-out was recorded at your old GP surgery. If you would like to remove your new national data opt-out, all you need to do is use the online service at www.nhs.uk/your-nhs-data-matters.

Other opt-outs registered at your GP surgery Any other types of opt-out that you have previously asked to be recorded by your GP surgery are not affected and will continue to be available and followed by your GP surgery. For instance, if you have asked your GP surgery to prevent your confidential patient information from leaving the GP surgery for purposes other than your individual care, this opt-out will continue to apply alongside your national data opt-out.

For instance, if you have asked your GP surgery to prevent your confidential patient information from leaving the GP surgery for purposes other than your individual care, this opt-out will continue to apply alongside your national data opt-out.

How is national data opt-out information processed? For more information about how NHS Digital collects, uses and discloses national data opt-outs please visit https://set-national-opt-out.service.nhs.uk/privacynotice.

Don’t know who we are? We, NHS Digital, exist to improve health and care by providing national information, data and IT services for patients, clinicians, commissioners and researchers. For more information visit www.digital.nhs.uk/about-nhs-digital.

For more information about the change to your opt-out, please visit www.content.digital.nhs.uk/yourinfo.

[Type text]For Office Use only. Date entered on EMIS:

Initials:Is the patient over 75?

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